=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659214625
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORLANDO PAIN MANAGEMENT CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2026
-----------------------------------------------------
Last Update Date | 04/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5425 S SEMORAN BLVD STE 11
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-4616
-----------------------------------------------------
Fax | 407-658-4617
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5425 S SEMORAN BLVD STE 11
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-4616
-----------------------------------------------------
Fax | 407-658-4617
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING AND CONTRACTING SPEC
-----------------------------------------------------
Name | PHAEDRA LUND SHUDRA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-785-4861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------